How to File a Reimbursement Claim Under Health Insurance?

When Can You File a Health Insurance Reimbursement Claim?

You can file a reimbursement claim under your health insurance policy in the following circumstances:

• If you want to obtain medical treatment at a non-network hospital of your insurance company
• If you were admitted to a non-network hospital of your insurance company during a medical emergency
• If your cashless claim request is rejected by the insurance company.

Steps to Raise a Reimbursement Health Insurance Claim

Here are the steps that you need to follow to file a reimbursement mediclaim insurance claim:

Step 1: Inform the Insurance Company

First, inform your insurance company or Third Party Administrator (TPA) about your emergency or planned hospitalization. In case you plan to get hospitalized for treatment, you must inform your insurer or TPA at least 48 hours before admission. On the other hand, if you have been admitted to a hospital due to a medical emergency, inform your insurer or TPA within 24 hours.

Step 2: Obtain Treatment

Once you have informed your insurer, simply obtain treatment at the hospital and focus completely on getting cured.

Step 3: Pay the Hospital Bill

At the time of getting discharged from the hospital, make sure to pay the entire hospital bill in full.

Step 4: Collect All Your Documents

Make sure to obtain all the medical documents related to your treatment, including the discharge summary and hospital bills, at the time of getting discharged from the hospital.

Step 5: Fill up the Claim Form

Once you have been discharged from the hospital, fill out the health insurance claim form of your insurance company. The form can be easily found on the insurer's website.

Step 6: Submit All the Documents to the Insurance Provider

Submit all the required documents to your insurance provider within the stipulated time frame, which is usually 15-30 days. To know the exact list of documents required, you can check your policy documents or contact your insurer.

Step 7: Document Verification and Evaluation of the Claim Request

The insurance company will verify all the documents received and cross-check with the coverage available under your health insurance policy. Once the documents have been verified, your claim will be either accepted or rejected within 30 days of receiving the documents. If the insurer requires more documents, they will let you know.

Step 8: Payment of Claim Amount

If your claim has been accepted, the insurance company will pay you the claim amount.

Documents Required for Reimbursement Health Insurance Claim

Here is a list of documents that you may need to submit while filing a reimbursement claim under your medical insurance policy:

• Duly filled health insurance claim form
• Copy of health card/ insurance policy
• Original investigation reports like blood test reports, X-rays, CT scans, etc.
• Copy of doctor consultation papers or prescriptions
• Original hospital discharge summary/ day care summary
• Original hospital bills
• Original medicine bills
• Original bill payment receipts
• Original implant sticker/invoice
• FIR or Medico-Legal Certificate (MLC) (in case of an accident)
• Copy of KYC documents
• NEFT details

Note: If the insured person passes away during hospitalization, additional documents, such as the original death summary and a legal heir certificate, may be required.

Can Medical Insurance Claims Be Denied?

Yes, health insurance claims can sometimes be denied, and this can happen for a variety of reasons. Below are some common reasons why health insurance claims might be denied:

• If the treatment or medical event is not included in your policy.
• If the policyholder does not provide all the required documents needed for settling the claim.
• Claims that are found to be unsupported by medical necessity or fraudulent will not be approved.
• If the policyholder hides or provides false information about a medical condition.
• Policies often have waiting periods for Pre-existing Diseases (PEDs) or certain illnesses. Claims made during this time are denied.

Things to Keep in Mind While Filing a Reimbursement Claim in Health
Insurance

Check out a few things that you should keep in mind while filing a health insurance reimbursement claim:

• Read your policy documents carefully and know what is covered and not covered under your policy.
• Go through the claim process of your insurance company while buying the policy so that you do not face any hassles at the time of filing the claim.
• Make sure you keep a copy of all the documents that you submit to your insurer, as you will have to submit the original documents.
• Check the waiting periods applicable under your policy and file a claim after the waiting period is over.

Remember to renew your mediclaim insurance policy on time as you cannot raise a claim if your policy has expired.